Screening and early diagnosis of frailty

Kenneth Rockwood Professor of Geriatric Medicine

Dalhousie University, Halifax Canada The University of Manchester, UK

Disclosures

• Copyright for the various frailty instruments I originated has been assigned to Dalhousie University.

• Methods have been published in the open access literature.

• Non-commercial use is free; users are asked not to commercialize the tools

Goals (my brief):

• Early diagnosis in relation to preventing & treating frailty

• Address frailty screening versus assessment.

• Remark on ethics & cost effectiveness of screening for frailty

• Note some benefits & challenges of a frailty policy.

The concept of frailty

• Frailty is an elevated state of risk

• Risk is compared with other people of the same chronological age

• Vaupel JW, Manton KG, Stallard E. The impact of heterogeneity in individual frailty on the dynamics of mortality. Demography 1979;16(3):439-54.

• Demographers/statisticians view it as a factor that is constant across the lifespan

• Clinicians view it as a variable/acquired factor

The older people get the more likely they are to die

100 0 10 20 30 40 50 60 70 80 90 100

0.002

0.007

0.018

0.050

0.135

0.368

Age (years)

Log scale

)exp( tR

Canadian cohort, born 1900

People age at different rates, defining frailty & fitness

Two approaches to operationalizing frailty: frailty as a

syndrome vs. frailty as a state

Operationalizing frailty as a syndrome

The frailty phenotype:

– Slow mobility

–Weakness

–Weight loss

–Decreased activities

– Exhaustion Fried et al.,. 2001;56 J Gerontol A Biol Sci Med Sci (3):M146-56.

The frailty index

Frailty Index = Number of deficits in an individual Total number of deficits measured

e.g. in a dataset with 50 health deficit measures, a person with 10 things wrong (10 deficits) has a

frailty index of 10/50 = 0.20.

Frailty as deficit accumulation: with age, most problems become more common

(Canadian National Population Health Survey, n= 66,580)

0 20 40 60 80 100 0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

arthritis

0 20 40 60 80 100 0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

vision problems

0 20 40 60 80 100 0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Mobility disability

0 20 40 60 80 100 0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

thyroid problems

Age (years)

Rockwood & Mitnitski Rev Clin Gerontol 2007;18:1-12.

National Population Health Survey - Mean Frailty Index at each cycle in relation to age

Frai

lty

Ind

ex (

or

pro

po

rtio

n o

f h

ealt

h d

efic

its)

Age (years)

10 20 30 40 50 60 70 80 90 100 0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

A

Pro

po

rtio

nal

dis

trib

uti

on

Rockwood et al., CMAJ 2011; E-pub April 28

From “Identifying Common Characteristics of Frailty Across Seven Scales”

Theou et al., Journal of the American Geriatrics Society Volume 62, Issue 5, pages 901-906, 2 APR 2014 DOI: 10.1111/jgs.12773 http://onlinelibrary.wiley.com/doi/10.1111/jgs.12773/full#jgs12773-fig-0002

At any age, women accumulate more deficits than do men. For men & women, deficit accumulation is highly correlated (r>0.95)

with mortality.

Mitnitski et al. J Am Geriatr Soc, 2005;53:2184-9

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Dea

th r

ate

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

Frailty index

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

Frai

lty

ind

ex

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Dea

th r

ate

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Dea

th r

ate

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.5 0

0.2

0.4

0.6

0.8

1

Frailty index

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

Frai

lty

ind

ex

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Dea

th r

ate

Identifying Common Characteristics of Frailty Across Seven Scales

Theou et al., Journal of the American Geriatrics Society Volume 62, Issue 5, pages 901-906, 2 APR 2014 DOI: 10.1111/jgs.12773 http://onlinelibrary.wiley.com/doi/10.1111/jgs.12773/full#jgs12773-fig-0001

Distribution of the Frailty Index

in 4 successive waves of the Chinese Longitudinal Health and Longevity Study;

Subjects aged 80-99 years at baseline; n= 6664

Bennett et al., Age Ageing 2013;42(3):372-7.

Instruments to screen for frailty

• The FRAIL scale

Based on five items, reflecting performance, self-reports and common co-morbidities

Morley JE et al., J Nutr Health Aging. 2012;16(7):601-8.

• The Canadian Study of Health & Aging Clinical Frailty Scale

Based on impairment in mobility, function, and self-rated health.

Rockwood K et al., Can Med Assoc J 2005;173(5):489-95.

FRAIL scale

• Did you feel worn out? or Did you feel tired?

(OR Did you have a lot of energy?)

• Ability to climb one flight of stairs

• Ability to walk 100 m

• Self-report of >5% weight loss

• ≤5 of (1) dementia; (2) heart disease; (3) depression; (4) arthritis; (5) asthma; (6) bronchitis/ emphysema; (7) diabetes; (8) hypertension; (9) osteoporosis; (10) stroke

List of Frailty:

1. Very Fit

2. Well

3. Managing Well

4. Vulnerable

5. Mildly Frail

6. Moderately Frail

7. Severely Frail

8. Very Severely Frail

9. Terminally ill

1. Canadian Study on Health and Aging 2. K Rockwood et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173:489-495

2. Well - People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally. Well older adults share most attributes of the very fit, except for regular, vigorous exercise. Like them, some may complain of memory symptoms, but without objective deficits.

4. Vulnerable – While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day. Many rate their health as no better than “fair”. Memory problems, if present, can begin to impact on function (e.g. having to look up familiar recipes, misplacing documents) but usually do not meet dementia criteria. Families often note some withdrawal – e.g. needing encouragement to go to social activities.

6. Moderately Frail – People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.

If a memory problem causes the dependency, often recent memory will be very impaired, even though they seemingly can remember their past life events well.

Frailty measurement in acutely ill older adults

Screening

– Rapid

– Easy to use

– Valid

– Reliable

– More sensitive than specific

Definitive evaluation

– Feasible

– Easy for routine use

– Valid

– Reliable

– Needs high specificity

Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability to Predict

All‐Cause Mortality: variable prevalence by scale

Theou et al., Journal of the American Geriatrics Society Volume 61, Issue 9, pages 1537-1551, 26 AUG 2013 DOI: 10.1111/jgs.12420 http://onlinelibrary.wiley.com/doi/10.1111/jgs.12420/full#jgs12420-fig-0001

Comprehensive Geriatric

Assessment Form

Comprehensive Geriatric Assessment Form:

co-morbidity & medications

Comprehensive Geriatric Assessment Form: value-added

Comprehensive Geriatric Assessment Form: function for care planning

Instrumental Activities of Daily

Living

Baseline (two weeks ago)

Current (today)

eFI Distribution (UK)

Courtesy of Prof. John Young, Leeds

0 10 20 30 40 50 60 70 0

0.2

0.4

0.6

0.8

1

A Frailty Index based on a Comprehensive Geriatric Assessment identifies a group at the highest risk of

dying (some of whom live 18 months).

FI-CGA

0.1

0.2

0.3

0.4 0.5

Survival time (months)

Surv

ival

pro

bab

ility

Rockwood, Rockwood, Andrew, Mitnitski.

J Am Geriatric Soc 2010;58:318-323

© 2014 Geriatric Medicine Research

Benefits & risks to a frailty policy: evaluating treatment in relation to frailty

Hypertension in the Very Elderly Trial

Frailty category, by Frailty Index

FI <=0.10

(n=533)

FI 0.11-0.21

(n=1238)

FI 0.22-0.34

(n=672)

FI >=0.35

(n=213)

Cardio-

vascular

events

Number of

events 26 97 68

40

Hazard Ratio

0.58

(0.26:1.31)

0.63

(0.42:0.94)

0.59

(0.36:0.96)

0.43

(0.22:0.83)

Stroke

Number of

events 11 38 26

20

Hazard Ratio

1.05 (0.31:3.59)

0.56 (0.29:1.08)

0.69 (0.32:1.50)

0.42 (0.17:1.07)

HYVET data, re-analysed by frailty level. Cox proportional hazard regression,

adjusted for age, sex and region

Warwick et al., submitted, April 2014

Mean

FI

Low Income Countries

(GDP<30,000)

High Income Countries

(GDP>30,000)

Frailty and National Income Mean FI and Gross Domestic Product (GDP)

R= -0.8; p<0.001

Theou O, et al., Age Ageing. 2013 Sep;42(5):614-9.

Benefits/risks to a frailty policy

Benefits

• Can identify where frail patients benefit most.

• Can spur reforms to make routine care less hazardous

• Can focus on outcomes most relevant to patients

• Can aid in understanding effectiveness of health care interventions, including at the population level

Risks

• Can result in rationing care for economic reasons, under the guise of “frail patients being unsuitable”.

• Any related costs savings might not be re-invested in better care for frail older adults.

• Can increase ageism in health care.

Summary

• Screening can indentify people at risk, across a fitness/frailty continuum

• Frailty screening can merge with assessment by more relevant routine data collection.

• Cost effectiveness not known, but risk of ageism is non-trivial.

• A frailty policy can allow for better care for everyone, by making routine care less ageist, less hazardous and more patient-focused.

Acknowledgments

Funding sources: • Fountain Innovation Fund of the QEII

Health Sciences Foundation • Canadian Institutes of Health Research • Mathematics of Information Technology

and Computer Science program, National Research Council

• Alzheimer Society of Canada • National Natural Science Foundation of

China • Dalhousie Medical Research Foundation

Colleagues & students:

• Arnold Mitnitski • Susan Howlett

• Olga Theou

• Xiaowei Song

• Melissa Andrew

• Samuel Searle

• Stephanie Bennett

• Tommy Brothers

• Judah Goldstein

• Kathryn Hominick

• Michael Rockwood

QUESTIONS